Tag: addiction

Two Reasons I’m Sceptical About Psychedelic Science

Photo by Marek Piwnicki

Michiel van Elk, Leiden University

Since I was young, I have been intrigued by altered states of consciousness, such as out-of-body experiences, paranormal phenomena and religious visions. I studied psychology and neuroscience to gain a better understanding of how these experiences come about. And in my scientific career, I have focused on the question of why some people are more prone to having these experiences than others.

Naturally, when I came across psychedelic science a couple of years ago, this field also sparked my academic interest. Here was an opportunity to study people who had a psychedelic experience and who claimed to have had a glimpse of ultimate reality. I started to research psychedelic experiences at Leiden University and founded the PRSM lab – a group of scientists from different academic backgrounds who study psychedelic, religious, spiritual and mystical experiences.

Initially, I was enthusiastic about the mind-transforming potential of psychedelics. These substances, when administered correctly, appear to be capable of enhancing people’s mental and physical wellbeing. They also increase feelings of connectedness to and concern for the environment.

Psychedelic therapy appeared to offer great potential for treating a wide variety of disorders, including depression, anxiety, addiction and post-traumatic stress disorder. This enthusiasm about the potentially transformative effects of psychedelics was reflected in positive media attention on this topic over the past few years. Michael Pollan, an American author and journalist, has brought psychedelics to an audience of millions with his book and Netflix documentary.

However, my initial optimism about psychedelics and their potential has changed into scepticism about the science behind much of the media hype. This is due to a closer scrutiny of the empirical evidence. Yes, at face value it seems as if psychedelic therapy can cure mental disease. But on closer inspection, the story is not that straightforward.

The main reason? The empirical evidence for the efficacy of and the working mechanisms underlying psychedelic therapy is far from clear.

Two issues

I wrote a critical review paper with my colleague Eiko Fried in which we listed the problems with the current clinical trials on psychedelic therapy. The main concern is called the “breaking blind problem”. In psychedelic studies, patients easily figure out if they have been randomly assigned to the psychedelic or the placebo group, simply because of the profound mind-altering effects of psychedelic substances.

This breaking-of-the-blind can actually result in placebo effect in patients in the psychedelic group: they finally get the treatment they’d been hoping for and they start feeling better. But it can also result in frustration and disappointment in patients assigned to the control group. They were hoping to get a miracle cure but now find out they will have to spend six hours on a placebo pill with their therapist.

As a consequence, any difference in therapeutic outcomes between the psychedelic and the placebo group is largely driven by these placebo and nocebo effects. (A nocebo effect is when a harmless treatment causes side-effects or worsening of symptoms because the person believes they may occur or expects them to occur.)

Knowing who received what also affects the therapists, who may be motivated to get more out of the therapy session if their patient got the “real deal”. And this problem is impossible to control for in so-called randomised controlled trials – still the gold standard in evaluating the effectiveness of drugs and treatments.

Also, non-clinical research on psychedelics faces problems. You may recall the graphic of a brain on psilocybin compared to one on a placebo (see below). Psilocybin increases the connections between different brain areas, which is represented in a colourful array of connecting lines.

This has become known as the “entropic brain hypothesis”. Psychedelics make your brain more flexible such that it returns to a child-like state of openness, novelty and surprise. This mechanism in turn has been hypothesised to underlie psychedelic therapy’s efficacy: by “liberating your brain” psychedelics can change entrenched and maladaptive patterns and behaviour. However, it turns out the picture is much more complicated than that.

Psychedelics constrict the blood vessels in your body and brain and this causes problems in the measurement of brain signals with MRI machines.

The graphic of the entropic brain may simply reflect the fact that the blood flow in the brain is dramatically altered under psilocybin. Also, it is far from clear what entropy exactly means – let alone how it can be measured in the brain.

A recent psilocybin study, which is yet to be peer-reviewed, found that only four out of 12 entropy measures could be replicated, casting further doubt on how applicable this mechanism of action is.

Although the story about psychedelics freeing your mind is compelling, it does not yet square well with the available empirical evidence.

These are just two examples that illustrate why it is important to be really cautious when you evaluate empirical studies in psychedelic science. Don’t trust findings at face value, but ask yourself the question: is the story too good or too simple to be true?

Personally, I have developed a healthy dose of scepticism when it comes to psychedelic science. I am still intrigued by psychedelics’ potential. They offer great tools for studying changes in consciousness. However, it is too early to conclude anything definite about their working mechanisms or their therapeutic potential. For this, we need more research. And I’m excited to contribute to that endeavour.

Michiel van Elk, Associate Professor, Cognitive Psychology, Leiden University

This article is republished from The Conversation under a Creative Commons license.

Read the original article.

New Non-invasive Brain Stimulation may One Day Treat Addiction, Depression and OCD

Source: CC0

Neurological disorders, such as addiction, depression, and obsessive-compulsive disorder (OCD), affect millions of people worldwide and are often characterised by complex pathologies involving multiple brain regions and circuits. These conditions are notoriously difficult to treat due to the intricate and poorly understood nature of brain functions and the challenge of delivering therapies to deep brain structures without invasive procedures.

In the rapidly evolving field of neuroscience, non-invasive brain stimulation enables the understanding and treating a myriad of neurological and psychiatric conditions, free of surgery or implants. Researchers, led by Friedhelm Hummel, who holds the Defitchech Chair of Clinical Neuroengineering at EPFL’s School of Life Sciences, and postdoc Pierre Vassiliadis, are pioneering a new approach in the field.

Their research, which is described in Nature Human Behaviour, makes use of transcranial Temporal Interference Electric Stimulation (tTIS). The approach specifically targets deep brain regions serving as control centres of several important cognitive functions and involved in different neurological and psychiatric pathologies.

“Invasive deep brain stimulation (DBS) has already successfully been applied to the deeply seated neural control centers in order to curb addiction and treat Parkinson, OCD or depression,” says Hummel. “The key difference with our approach is that it is non-invasive, meaning that we use low-level electrical stimulation on the scalp to target these regions.”

The innovative technique is based on the concept of temporal interference, initially explored in rodent models, and now successfully translated to human applications by the EPFL team. In this experiment, one pair of electrodes is set to a frequency of 2000Hz, while another is set to 2080Hz. Thanks to detailed computational models of the brain structure, the electrodes are specifically positioned on the scalp to ensure that their signals intersect in the target region.

It is at this juncture that the magic of interference occurs: the slight frequency disparity of 80Hz between the two currents becomes the effective stimulation frequency within the target zone. The brilliance of this method lies in its selectivity; the high base frequencies (eg, 2000Hz) do not stimulate neural activity directly, leaving the intervening brain tissue unaffected and focusing the effect solely on the targeted region.

The focus of this latest research is the human striatum, a key player in reward and reinforcement mechanisms. “We’re examining how reinforcement learning, essentially how we learn through rewards, can be influenced by targeting specific brain frequencies,” says Vassiliadis. By applying stimulation of the striatum at 80Hz, the team found they could disrupt its normal functioning, directly affecting the learning process.

The therapeutic potential of their work is immense, particularly for conditions like addiction, apathy and depression, where reward mechanisms play a crucial role. “In addiction, for example, people tend to over-approach rewards. Our method could help reduce this pathological overemphasis,” Vassiliadis, who is also a researcher at UCLouvain’s Institute of Neuroscience, points out.

Vassiliadis, lead author of the paper, a medical doctor with a joint PhD, describes tTIS as using two pairs of electrodes attached to the scalp to apply weak electrical fields inside the brain. “Up until now, we couldn’t specifically target these regions with non-invasive techniques, as the low-level electrical fields would stimulate all the regions between the skull and the deeper zones – rendering any treatments ineffective. This approach allows us to selectively stimulate deep brain regions that are important in neuropsychiatric disorders,” he explains.

Furthermore, the team is exploring how different stimulation patterns can not only disrupt but also potentially enhance brain functions. “This first step was to prove the hypothesis of 80Hz affecting the striatum, and we did it by disrupting it’s functioning. Our research also shows promise in improving motor behaviour and increasing striatum activity, particularly in older adults with reduced learning abilities,” Vassiliadis adds.

Hummel, a trained neurologist, sees this technology as the beginning of a new chapter in brain stimulation, offering personalised treatment with less invasive methods. “We’re looking at a non-invasive approach that allows us to experiment and personalise treatment for deep brain stimulation in the early stages,” he says. Another key advantage of tTIS is its minimal side effects. Most participants in their studies reported only mild sensations on the skin, making it a highly tolerable and patient-friendly approach.

Hummel and Vassiliadis are optimistic about the impact of their research. They envision a future where non-invasive neuromodulation therapies could be readily available in hospitals, offering a cost-effective and expansive treatment scope.

Original written by Michael David Mitchell. The original text of this story is licensed under Creative Commons CC BY-SA 4.0. Edited for style and length.

Source: Ecole Polytechnique Fédérale de Lausanne

New Online Recovery School a First for South Africa

South Africa is a traumatised nation

Photo by Steinar Engeland on Unsplash

Dr Siya Mjwara, founder of the AskDrSiya Psychotherapy and Wellness Coaching Practice, has just launched the first online recovery school in South Africa. The Recovery School will support individuals in identifying and confronting their challenges and businesses in developing and implementing wellness solutions in order to reduce absenteeism and improve productivity, as well as overall workplace culture. Dr Mjwara will provide a supportive and transformative environment where healing and growth are possible for all.

She says, “We create a virtual sanctuary where individuals can find healing, empowerment and community support. We strive to cultivate a space where you can reclaim your life and thrive, no matter what you’ve been through.

“After 17 years of working with individuals, couples and families, I can say, without a doubt, that we South Africans are a traumatised nation. Unfortunately, many of us are completely unaware of how our traumas are negatively impacting our lives, as well as the decisions we take on a daily basis. Recently, I’ve been hearing people say, “avoid dating anyone who has never been to therapy”. This is an indication that more of us are recognising how unresolved trauma can negatively impact our relationships.

“Besides our personal experiences, such as childhood trauma, relationship, family and workplace traumas, many of us are still dealing with the effects of intergenerational trauma.

This is part of the background that informs the vision for The Recovery School. My wish is for individuals to not only cope with trauma, but also to be able to thrive and become the best version of themselves. It takes courage to face your fears and begin living authentically, and you don’t need to walk the journey alone.

The school’s programmes are primarily designed to enable individuals to

  1. Rediscover themselves
  2. Break free from limiting beliefs
  3. Cultivate resilience
  4. Forge meaningful connections
  5. Live fully in the present
  6. Achieve their goals

Dr Mjwara BSW Hons (UWC), MA FCS (UWC), Dphil (UNIZULU) can be contacted on Ask@DrSiya.co.za or 079 772 1950.

Running away from Life’s Stresses: The Phenomenon of Exercise Addiction

Photo by Quino Al on Unsplash

Recreational running offers a lot of physical and mental health benefits – but some people can develop exercise dependence, a form of addiction to physical activity which can cause health issues. Shockingly, signs of exercise dependence are common even in recreational runners. A study published in Frontiers in Psychology investigated whether the concept of escapism can help us understand the relationship between running, well-being, and exercise dependence.

“Escapism is an everyday phenomenon among humans, but little is known regarding its motivational underpinnings, how it affects experiences, and the psychological outcomes from it,” said Dr Frode Stenseng of the Norwegian University of Science and Technology, lead author of the paper.

Running to explore or to evade?

“Escapism is often defined as ‘an activity, a form of entertainment, etc. that helps you avoid or forget unpleasant or boring things.” In other words, many of our everyday activities may be interpreted as escapism,” said Stenseng. “The psychological reward from escapism is reduced self-awareness, less rumination, and a relief from one’s most pressing, or stressing, thoughts and emotions.”

Escapism can restore perspective, or it can act as a distraction from problems that need to be tackled. Escapism which is adaptive, seeking out positive experiences, is referred to as self-expansion. Meanwhile maladaptive escapism, avoiding negative experiences, is called self-suppression. Effectively, running as exploration or as evasion.

“These two forms of escapism are stemming from two different mindsets, to promote a positive mood, or prevent a negative mood,” said Stenseng.

Escapist activities used for self-expansion have more positive effects but also more long-term benefits. Self-suppression, by contrast, tends to suppress positive feelings as well as negative ones and lead to avoidance.

Self-suppression associated with exercise dependence

The team recruited 227 recreational runners, half men and half women, with widely varying running practices. They were asked to fill out questionnaires which investigated three different aspects of escapism and exercise dependence: an escapism scale which measured preference for self-expansion or self-suppression, an exercise dependence scale, and a satisfaction with life scale designed to measure the participants’ subjective well-being.

The scientists found that there was very little overlap between runners who favoured self-expansion and runners who preferred self-suppression modes of escapism. Self-expansion was positively related with well-being, while self-suppression was negatively related to well-being. Self-suppression and self-expansion were both linked to exercise dependence, but self-suppression was much more strongly linked to it. Neither escapism mode was linked to age, gender, or amount of time a person spent running, but both affected the relationship between well-being and exercise dependence. Whether or not a person fulfilled criteria for exercise dependence, a preference for self-expansion would still be linked to a more positive sense of their own well-being.

Although exercise dependence corrodes the potential well-being gains from exercise, it seems that perceiving lower well-being may be both a cause and an outcome of exercise dependency: the dependency might be driven by lower well-being as well as promoting it.

Similarly, experiencing positive self-expansion might be a psychological motive that promotes exercise dependence.

“More studies using longitudinal research designs are necessary to unravel more of the motivational dynamics and outcomes in escapism,” said Stenseng. “But these findings may enlighten people in understanding their own motivation, and be used for therapeutic reasons for individuals striving with a maladaptive engagement in their activity.”

Source: Frontiers

Cortisol Levels may Predict Addiction Recovery Success

Depression, young man
Source: Andrew Neel on Unsplash

A new study found that lower initial cortisol levels may serve as a predictor for retention in treatment programs for substance use disorder.

The prospective observational study examined the salivary cortisol, stress exposure, adverse childhood experiences (ACEs) and treatment retention of males enrolled in abstinence-based, residential alcohol and drug recovery programs. Their findings were published last month in Alcoholism: Clinical and Experimental Research.

Cortisol levels reflect a physiological response to stress. In this case, researchers found that participants who remained in the treatment program less than 90 days had significantly higher initial cortisol levels than those who remained in the program longer than 90 days. Further, a Cox proportional hazards model indicated that elevated salivary cortisol, marital/relationship status and ACEs score correlated significantly with hazards of discontinuing the program early.

“Our hope is that these findings will lead to cortisol as a biomarker that can help clinicians determine which individuals might need a more intensive therapeutic approach,” said Todd H. Davies, Ph.D., associate director of research and development at the Joan C. Edwards School of Medicine and corresponding author on the study.

In collaboration with Recovery Point, the researchers have a larger follow-up study underway that seeks to identify the clinical significant levels of cortisol. This expanded study also includes a more representative population and examine the hormone oxytocin.

Source: Marshall University Joan C. Edwards School of Medicine

Teens Have Triple the Risk of Developing Cannabis Addiction

Cannabis plants
Photo by Harrison Haines on Pexels

Adolescents have more than three times the risk of developing a cannabis addiction than adults, although they may only have the same risk of other mental health problems related to the drug, according to a new study published in the Journal of Psychopharmacology.

The study, led by King’s College London and University College London, found that adolescent cannabis users had the same odds for higher levels of subclinical depression or anxiety than adults cannabis users, nor were they more vulnerable than adult users to cannabis’s associations with psychotic-like symptoms.

These findings build on a separate study by the same team that found adolescents were not more vulnerable to associations between chronic cannabis use and cognitive impairment.

Lead author Dr Will Lawn said: “There is a lot of concern about how the developing teenage brain might be more vulnerable to the long-term effects of cannabis, but we did not find evidence to support this general claim.

“Cannabis addiction is a real issue that teenagers should be aware of, as they appear to be much more vulnerable to it than adults.

“On the other hand, the impact that cannabis use has during adolescence on cognitive performance or on depression and anxiety may be weaker than hypothesised.

“But we also replicated previous work that if someone becomes addicted to cannabis, that may increase the severity of subclinical mental health symptoms. Given adolescents are also at a greater risk of experiencing difficulties with mental health than adults, they should be proactively discouraged from regular cannabis use.”

The findings in both papers come from the CannTeen study, which is comparing the effects of regular cannabis use among adolescents and adults, while also comparing to age-matched controls (non-users of cannabis), a completely novel design.

The study involved 274 participants, including 76 adolescents (aged 16–17) who used cannabis one to seven days per week, alongside similar numbers of adult (aged 26–29) users, and teenage and adult control (comparison) participants, who all reported their cannabis use over the last 12 weeks and responded to mental health questionnaires. The cannabis users in the study, on average, used it four times per week. The adolescent and adult users were also carefully matched on gender, ethnicity, and type and strength of cannabis.

The researchers found that adolescent cannabis users were three and a half times as likely to develop severe ‘cannabis use disorder’ (ie addiction) than adult users, a finding which is in line with previous studies. Cannabis use disorder is defined by symptoms such as cravings; cannabis use contributing to failures in school or work; heightened tolerance; withdrawal; interpersonal problems caused by or exacerbated by cannabis use; or intending to cut back without success. Oof the teenage cannabis users studied, 50% had six or more cannabis use disorder symptoms, qualifying as severe cannabis use disorder.

Among people of any age, previous studies have found that roughly 9–22% of people who try the drug develop cannabis use disorder, and that risk is higher for people who tried it at a younger age, a finding which has now been robustly replicated.

The researchers say that adolescents might be more vulnerable to cannabis addiction because of factors such as increased disruption to relationships with parents and teachers, a hyper-plastic (malleable) brain and developing endocannabinoid system (the part of the nervous system that THC in cannabis acts upon), and an evolving sense of identity and shifting social life.

Adolescent users had greater odds than adult users or adolescent non-users of developing psychotic-like symptoms, but analysis showed that this is because all adolescents, and all cannabis users, are more likely to newly develop psychotic-like symptoms, rather than a different effect of cannabis for teenagers than adults. Thus, there was no interaction between cannabis use and being an adolescent. The researchers say this fits in with prior evidence that cannabis use may increase the likelihood of developing a psychotic disorder such as schizophrenia, but they warn their study did not investigate the risk of clinical psychosis or schizophrenia.

The researchers found that neither teenage nor adult cannabis users were more likely to develop depressive or anxiety symptoms than non-users. Only the adolescents that have severe cannabis use disorder had worse mental health symptoms, but the researchers caution that the small sample size for this group limits their confidence in this finding.

The separate study found that cannabis users were no more likely to have impaired working memory or impulsivity. Cannabis users were more likely to have poor verbal memory (remembering things said to you); this effect was the same in adults and teenagers, so again there was no adolescent vulnerability. However, the researchers caution that cannabis use could impact school performance during a key developmental stage of life.

The researchers caution that these findings were cross-sectional (only looking at one time point), and that longitudinal analyses of how their participants changed over time are ongoing.

Senior author Professor Val Curran (UCL Clinical Psychopharmacology Unit, UCL Psychology & Language Sciences) said: “Our findings suggest that schools should be teaching pupils more about the risk of addiction to cannabis, which has been neglected in drugs education. Becoming addicted to cannabis is a serious problem in itself, but it can also increase the likelihood of other mental health problems. Teenagers should therefore be informed of their greater risk of addiction.”

Source: King’s College London

Single Pathway Controls Drug Withdrawal-induced Anxiety

Depression, young man
Source: Andrew Neel on Unsplash

New research published today in Cell Reports finds that drug withdrawal-induced anxiety and return to drug seeking behaviours are controlled by a single pathway in the brain and are centred on dopamine cells, which are normally associated with reward behaviours.

Addiction occurs in phases: the initial drug exposures are rewarding, and then repeated administration leads to tolerance or sensitisation to the drug’s effects, with withdrawal leading to anxiety and a negative affective state, which, in turn, contributes to a return to drug taking or seeking.

“In order to prevent relapse among drug users, specifically cocaine users, we need to understand the factors in the brain that contribute to drug seeking behaviours and the vulnerability to relapse,” said Kevin Beier, PhD, assistant professor of physiology and biophysics from the University of California, Irvine. “In this study, we identified a brain circuit that is responsible for drug withdrawal-induced anxiety as well as relapse-related behaviour, along with the identification of a potential target for therapeutic interventions.”

The negative affective state induced by drug withdrawal is a critical factor in the relapse of drug users.

“Both the drug withdrawal-induced anxiety and reinstatement of drug seeking are controlled by a single pathway centred around dopamine cells in the ventral midbrain,” explained Dr Beier. “That a single pathway controls both sets of behavioural changes may help to explain many addiction-related behavioural phenomena. Importantly, it links them both directly to dopamine, which is more typically linked to reward-related behaviours.”

While midbrain dopamine circuits are central to motivated behaviours, just how experience modifies these circuits to facilitate subsequent behavioural adaptations is not well understood. This study demonstrates the selective role of a ventral tegmental area dopamine projection to the amygdala for cocaine induced anxiety, but not for cocaine reward or sensitisation. Silencing this projection prevents development of anxiety during protracted withdrawal after cocaine use.

According to the National Center for Drug Abuse Statistics, there are roughly 70 000 drug overdoses each year in the United States. In 2017, nearly one in five drug overdose deaths was cocaine-related, with the highest rate of cocaine-related overdoses and deaths occurring among non-Hispanic black populations. Between 2012 and 2018, the rate of cocaine-related overdose deaths increased from 1.4 to 4.5%. The American Addiction Centers state recent drug relapse statistics show that more than 85% of individuals relapse and return to drug use within a year following treatment.

Source: University of California – Irvine

Glutamate and Dopamine Interact in Addiction

Image source: Pixabay

Drug addiction is a psychiatric disorder for which no pharmacological treatment with long-term efficacy currently exists: all addictive substances have in common the fact that they raise concentrations of the neurotransmitter dopamine within brain regions forming the neural reward circuit.

This increase in dopamine levels results in long-lasting alteration of signal transmission that is dependent on another neurotransmitter, glutamate, which causes addictive behaviours. Through a new study in mice and humans, an international team including scientists from the CNRS, INRAE, the CEA, Sorbonne University, Paris-Saclay University, the University of Bordeaux, and Université Côte d’Azur has uncovered, the molecular bases of this deleterious interplay between dopamine and glutamate.

The researchers’ findings demonstrate that the inhibition of interactions between dopamine and glutamate receptors prevents pathological behaviours provoked by cocaine in mice, without altering natural reward processing. Their findings, published in Science Advances, will help pave the way for the development of new therapeutic strategies to treat addiction, and a wider spectrum of psychiatric disorders.

Source: CNRS (Délégation Paris Michel-Ange)

Studies Find Females More Susceptible To Addiction

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Several new studies focusing on sex differences in pain and addiction suggest that females could be more susceptible to drug addiction and addiction-like behaviours than males. Researchers also investigated how sleep deprivation affected the likelihood of relapse, partly driven by hormone differences in females and males. The studies will be presented at the American Physiological Society’s seventh conference on New Trends in Sex and Gender Medicine from 19 to 22 October.

This study used a rat model to investigate the connection between opioid abstinence and persistent sleep loss and its impact on the body’s central stress response system. Researchers specifically found persistent sleep disruption may cause or perpetuate abnormalities in their hypothalamic-pituitary adrenal axis. These abnormalities increase the risk of vulnerability to relapse during oxycodone abstinence in some individuals. Scientists are now working to identify susceptibility factors that play a role in boosting the risk of relapse. Adequate sleep may be critical for successful recovery from opioid addiction.

Researchers conducting this study explored how the opioid epidemic in the US continues and evolved during the ongoing COVID pandemic. Women have made up the majority of those prescribed opioids for pain treatment. Prescribed opioids for pain management became the primary conduit to abuse and addiction for women, and the researchers found that mitigations in opioid prescriptions have been followed by increases in the use of other substances, such as heroin and fentanyl, in both men and women. While the rate of opioid use and overdose is higher in men, women have a higher rate of overdose death. Understanding how opioid use and addiction differ in their effect on men and women is key to ending the epidemic.

A rat model was also used to evaluate sex differences in vulnerability to addiction. Their results indicate activation of a specific subset of receptors for oestrogens enhances established cocaine-seeking behaviors in female rats. In male rats, the preference for cocaine under the same circumstances was reduced, involving the area of the brain linked to compulsive behaviours. Females show a greater response than males to stimulants such as amphetamine and cocaine in part due to the gonadal hormone oestradiol, which is one of the three forms of oestrogen. The hope is these results will lead to a better understanding of the mechanisms of addiction-related behaviors and the development of sex-specific treatments for addiction.

Source: American Physiological Society

High-dose Buprenorphine in ED Could Improve Opioid Abuse Outcomes

Photo by Mat Napo on Unsplash
Photo by Mat Napo on Unsplash

High-dose buprenorphine therapy, provided under emergency department care, is safe and well tolerated in people with opioid use disorder experiencing opioid withdrawal symptoms, according to a study supported by the National Institutes of Health’s National Institute on Drug Abuse (NIDA).

Lower doses of buprenorphine, a medication approved by the US Food and Drug Administration to treat opioid use disorder, are the current standard of care. Higher doses, however, could extend the period of withdrawal relief for people after being discharged from the emergency department that could help them better seek care. 

“Emergency departments are at the front lines of treating people with opioid use disorder and helping them overcome barriers to recovery such as withdrawal,” said Nora D Volkow, MD, director of NIDA. “Providing buprenorphine in emergency departments presents an opportunity to expand access to treatment, especially for underserved populations, by supplementing urgent care with a bridge to outpatient services that may ultimately improve long-term outcomes.”

Presently, some emergency departments already administer higher buprenorphine doses to treat withdrawal and opioid use disorder. They do this as a response to the growing potency in illicit opioid drug supplies and delays in access to follow-up care, but this practice has not been evaluated previously.

Researchers used a retrospective chart review to analyse data from electronic health records documenting 579 emergency department visits at the Alameda Health System Highland Hospital in California, made by 391 adults with opioid use disorder in 2018. Many patients were from vulnerable populations, with 23% experiencing homelessness and 41% having a psychiatric disorder.

In 63% of cases, clinicians administered more than the standard upper limit of 12 mg of sublingual buprenorphine during emergency department induction, and in 23% of cases, patients were given 28 mg or more. Higher doses of buprenorphine were seen to be safe and tolerable, and there were no reports of respiratory problems or drowsiness among those given the higher doses. The few serious adverse events that occurred were determined to be unrelated to high-dose buprenorphine therapy.

Studies have shown that initiating buprenorphine in emergency departments improves engagement in treatment and is cost effective, but barriers to the medication’s use in the US persist, with restrictions on what training is required, how much can be administered and for how long. Recent changes to prescribing guidelines by the US Department of Health and Human Services now let some clinicians treating up to 30 patients to prescribe buprenorphine without the previous training and services criteria.

“Once discharged, many people have difficulty linking to follow-up medical care,” explained study leader Andrew A Herring, MD, of Highland Hospital Department of Emergency Medicine. “Adjusting the timing and dosage of buprenorphine in the emergency department, along with resources and counseling aimed at facilitating the transition to outpatient services, may provide the momentum needed to access continuing care.”

“This study enhances the evidence we know about emergency-department buprenorphine induction, and could be a gamechanger, particularly for vulnerable populations who would likely benefit from a rapid induction at the time of the visit,” said study author Gail D’Onofrio, MD, of Yale University. Dr D’Onofrio published the original studies on emergency department-initiated buprenorphine, as well as recent consensus recommendations on the emergency department treatment of opioid use disorder.
The researchers noted that their findings need confirmation in other emergency departments. Nevertheless, this study suggests that with proper support and training, emergency medicine providers may safely and effectively initiate high-dose buprenorphine therapy.

Source: NIH

Journal information: JAMA Network Open (2021). DOI: 10.1001/jamanetworkopen.2021.17128